Name *

Telephone / Mobile no *

E-Mail Address *

Nature of addiction
Select Alcohol Heroin Methadone Cocaine Crack Polyuse Other

Cost per day?
Select Free £10 to £20 £20 to £40 £40 to £60 £60 to £80 £80 to £100 £100.00 +

Has the individual attended detox before?
Select Yes No

If 'Yes' please list reason for relapse?

Preferred treatment location?
Select Manchester London

How did you hear about us?
Select Television Radio Internet Newspaper Referral Other

Comments*